Provider Demographics
NPI:1962291666
Name:NICHOLS, THERA
Entity type:Individual
Prefix:PROF
First Name:THERA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 WOLF LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9490
Mailing Address - Country:US
Mailing Address - Phone:517-522-5013
Mailing Address - Fax:517-522-5359
Practice Address - Street 1:3775 WOLF LAKE RD
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9490
Practice Address - Country:US
Practice Address - Phone:517-522-5013
Practice Address - Fax:517-522-5359
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI380418074310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility